A 47-year-old woman presented with a 1-year history of an erythematous plaque on her left leg. The plaque was not painful when it first developed, but it became tender when it ulcerated. She denied trauma and systemic symptoms. There was no previous treatment. Her medical history was significant for type 2 diabetes, chronic renal failure, cardiomyopathy, and gouty arthritis.

Physical examination revealed an 11 × 21-cm erythematous plaque on the lower area of the left leg, with scattered firm, white papules and areas of ulceration (Figure 1), and a 7-cm, rubbery, nontender, reddish yellow nodule on the dorsal aspect of the right hand (Figure 2). Also, pink to white firm nodules were seen in a linear distribution on the lateral aspect of the fingers, the dorsal aspect of both hands, and the extensor aspect of the forearms. A punch biopsy specimen was obtained from the plaque on the left lower leg area (Figure 3).